QUERI Investigators Improve VA Providers' Lack of Awareness about the Risk in Prescribing Inhaled Corticosteroids for COPD

Apri 1, 2020

Takeaway: QUERI study shows providers lack awareness of the risk in prescribing inhaled corticosteroids for COPD and the recommended alternatives to their use. VA is trying to de-implement the use of corticosteroids for Veterans with COPD. HSR&D research has evaluated their continued use and the importance of increased dissemination/awareness to improve provider understanding and intentions to use alternatives. Investigators are testing a proactive electronic consult (e-consult), initiated by pulmonary specialists just before a patient has a scheduled visit. The e-consult proposes any guideline-recommended changes, such as de-implementing an inhaled corticosteroid. The QUERI team has been asked to expand the proactive e-consult intervention from 13 primary care clinics affiliated with two urban VA healthcare systems to VISN 17.

More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations – based on evidence of harm (i.e., increased risk of severe pneumonia), the availability of safer medications, and the lack of evidence for benefit to patients with less severe disease. Investigators in this study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Findings show:

• Of the Veterans with COPD in this study cohort, 1,299 (15%) were prescribed an inhaled corticosteroid. However, 792 (61%) of these prescriptions were not clinically indicated.
• Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia.

However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications.

Investigators are testing a proactive electronic consult (e-consult), initiated by pulmonary specialists just before a patient has a scheduled visit. The e-consult proposes any guideline-recommended changes, such as de-implementing an inhaled corticosteroid, in the form of an unsigned note or unsigned order. It also contains a brief rationale and link to guidelines. The QUERI team has been asked to expand the proactive e-consult intervention from 13 primary care clinics affiliated with two urban VA healthcare systems to VISN 17 (encompassing most of Texas).

Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne S, Wiener RS, Feemster L, Udris E, Au DH, and Helfrich C. De-Implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers’ Perspectives. Journal of General Internal Medicine. August 8, 2019; Epub ahead of print.

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